Oral Steroids for Lumbar Radiculopathy
Oral steroids, including methylprednisolone, are not recommended for treating lumbar radiculopathy, as multiple high-quality trials consistently demonstrate no benefit for pain relief or functional improvement, while significantly increasing adverse events.
Evidence Against Oral Steroids
The most definitive evidence comes from a 2017 systematic review for the American College of Physicians, which analyzed 10 trials evaluating systemic corticosteroids for radicular low back pain 1:
- Six trials consistently found no differences between systemic corticosteroids and placebo in pain relief for radicular low back pain of varying duration 1
- The largest good-quality trial (n=269) showed only small functional effects (ODI difference of 7.4 points at 52 weeks), while two other trials found no functional benefits 1
- Two trials found no effect on the likelihood of requiring spine surgery 1
Significant Adverse Events
The harm profile is substantial and clinically meaningful 1:
- Any adverse event: 49% vs 24% with placebo (P < 0.001) in the largest trial using oral prednisone 60 mg/day 1
- Insomnia: 26% vs 10% (P = 0.003) 1
- Nervousness: 18% vs 8% (P = 0.03) 1
- Increased appetite: 22% vs 10% (P = 0.02) 1
Clinical Algorithm
For patients presenting with lumbar radiculopathy:
Do not prescribe oral corticosteroids as they provide no meaningful benefit over placebo for pain or function 1
Consider epidural steroid injections only if conservative measures fail, though evidence is mixed:
- Transforaminal epidural injections may provide short-term benefit in select patients 2, 3
- One older trial found no efficacy for epidural methylprednisolone versus saline in patients with radiographic nerve root compression 4
- A 2024 study suggests nonparticulate steroids (dexamethasone) may be safer and more effective than particulate steroids (methylprednisolone) for epidural use, with 87.5% requiring zero repeat injections versus 71.4% with particulate steroids (P < 0.001) 3
Pursue alternative evidence-based treatments rather than oral steroids, as the risk-benefit ratio is unfavorable
Critical Pitfalls to Avoid
Do not confuse the evidence base: The provided guidelines for Crohn's disease, ulcerative colitis, and sudden hearing loss demonstrate steroid efficacy in those conditions 1, but this does not translate to lumbar radiculopathy, where the pathophysiology and evidence are entirely different 1.
Do not use prolonged courses: Even if considering steroids despite the evidence, courses beyond 10-14 days dramatically increase complications without additional benefit 1.
Recognize contraindications: Patients with poorly controlled diabetes, labile hypertension, history of steroid-induced psychosis, or prior serious steroid complications should absolutely avoid systemic corticosteroids 1.